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Medicine and Culture: Transcultural Needs in Modern Western Societies

Abstract

A distinction can be made between two types of cultural diversity in the practice of medicine: cultural diversity among the individuals involved in healthcare settings (i.e. doctors, nurses, patients, etc.), and diversity in the health paradigms now prevalent in contemporary modern societies (e.g. orthodox Western medicine, Chinese acupuncture, Indian ayurveda and Yorùbá medicine). In contrast to the received view, in which diversity is regarded as 'challenging' or 'problematic' for the provision and delivery of optimal healthcare, this paper argues that because health, wellbeing and wellness are themselves cultural goods in all paradigms of medicine, it is always possible to perform transcultural assessments of the methods, theories and practices adopted in specific paradigms of medicine.
112 AvMA Medical & Legal Journal
The AvMA Medical & Legal Journal 2007 Volume 13 Number 3
Medicine and culture: transcultural needs in modern
Western societies
Kólá Abímbólá
Abstract
A distinction can be made between two types of cultural diversity in the practice of medicine: cultural
diversity among the individuals involved in healthcare settings (i.e. doctors, nurses, patients, etc.), and
diversity in the health paradigms now prevalent in contemporary modern societies (e.g. orthodox
Western medicine, Chinese acupuncture, Indian ayurveda and Yorùbá medicine). In contrast to the
received view, in which diversity is regarded as 'challenging' or 'problematic' for the provision and
delivery of optimal healthcare, this paper argues that because health, wellbeing and wellness are
themselves cultural goods in all paradigms of medicine, it is always possible to perform transcultural
assessments of the methods, theories and practices adopted in specific paradigms of medicine.
Introduction
It is customary in contemporary Western cultures to dis-
tinguish between traditional and alternative medicine.
Traditional medicine refers to orthodox medicine –
medicine as practised by doctors who have undergone
training in medical schools that are approved by medical
associations. Alternative medicine is a generic term used
to describe any other approach that employs principles
and methods that are different from those of orthodox
medicine. Chinese acupuncture, Indian ayurveda, Yorùbá
medicine and the healing aspects of Sufism are all
regarded as alternative medicines by many Western soci-
eties. Oftentimes, these medical alternatives (with their
different values, methods, beliefs and conceptions –
paradigms for short) clash with the Western (orthodox)
paradigm of medicine.This paper is an exploration of the
rationality of decision-making vis-à-vis the ethical prob-
lems that arise when a physician and a patient adhere to
different paradigms of medicine in ‘multicultural’ Western
societies.
The main problem is that multiculturalism tends to
lead to relativism. Multiculturalism may be defined as ‘a
societal-intellectual movement that promotes the value of
diversity as a core principle and insists that all cultural
groups be treated with respect and as equals’.1If physi-
cians are required to respect and tolerate the values, beliefs
and conceptions of their patients, then we may end up
with irrational and illogical decisions, and indeed, in some
situations, medical practitioners may be forced to acqui-
esce to various types of injustices. Should we simply
accept these illogical and relativistic conclusions as conse-
quences of living in multicultural societies? This paper
maintains that we need to make a crucial distinction
between multiculturalism and transculturalism.
Multiculturalism would maintain that no medicocultural
practice or value can be evaluated independently of its
associated paradigm, whereas transculturalism maintains
that the values, methods and beliefs of each paradigm can
themselves be subject to evaluation, while at the same
time treating them with respect and regarding them as
equals. My argument is that because medicine is a cultural
good in all paradigms of medicine, it is always, in fact,
possible to engage in transcultural evaluations when it
comes to issues of health, wholeness and wellness. Simply
put, because medicine is itself a cultural good, the
paradigms of medicine may sometimes conflict but, ulti-
mately, these paradigms are not incommensurable.
Medicine as a cultural good
The word ‘culture’ has at least two everyday usages: on
the one hand, it means ‘high culture’, that is, the ‘best’
exemplars of a society’s achievements and products in the
arts, literature, music, science and technology. The second
sense of the word ‘culture’ is that in which it refers to the
artificial cultivation and growth of microscopic organ-
isms, species and plants. This second sense of the word
derives its meaning from the verb ‘to cultivate’, ‘to hus-
band’ (in the sense of agricultural techniques). These two
senses of culture are linked:for not only are achievements
in the arts, literature, science, etc. ‘artificial’ in that they
are human creations, the elements of ‘high’ (and, of
course, ‘low’) culture have to be cultivated, learnt, nur-
tured and transmitted otherwise they will wither away
and die.
Medicine is, at the very least, a cultural good in these
two senses: it is about the achievements of a society in its
quest to understand itself as the human knower, just as
much as it is about the cultivation and transference of
knowledge about us as the knowing subject. There are
three dimensions to these cultural aspects of medicine: the
communal, the individualistic and the practical.
Culture as communal practices
Medicine is communal: it is the shared set of beliefs, prac-
tices and methods that make up a society’s communal bank
of knowledge on the prevention, alleviation and curing of
diseases and injuries. Medicine in this communal sense is
reflected in the social activities of a people as a group. One
of the clearest illustrations of the communal dimensions of
medicine is public health concerns in the protection, pro-
motion and restoration of people’s health. Solutions to
Kólá Abímbólá,Lecturer in Law, University of Leicester,
Leicester LE1 7RH, UK
07.13.3.avma.07.pps 4/21/07 11:03 am Page 6
Here is a quick recapitulation of these goods.
1. Medicine is a repository of a society’s achievements in
the human sciences.
2. These achievements rely on cultivated techniques that
have to be learnt, nurtured and transmitted.
3. In the process of accepting and transmitting them,
they become part of a community or society’s general
belief structures.
4. At the same time, they will become part of the spe-
cific beliefs accepted by specific individuals.
5. Finally, the acceptance and reliance of items 1–4
makes medical beliefs practical beliefs; that is, they
become heuristic action-guiding principles on the
basis of which we moderate, regulate and control
action and inaction in issues of health, wholeness and
wellness.
In the next section, I will illustrate how these five
senses of medicine as a cultural good impact on the
human condition in medical decision-making.
Medicine and practical beliefs
The United States Patient Self-Determination Act (PSDA)
[1990] came into force on 1 December 1991. The PSDA
requires healthcare providers (including: hospitals, nursing
homes, hospice programs, home health agencies and health
management organizations) to inform adults (at the time
of inpatient admission or enrolment) about certain rights.
These include: (1) the right to participate in and to direct
their own healthcare decisions during an informed con-
sent discussion; (2) the right to accept or refuse medical or
surgical treatment; (3) the right to prepare an advance
directive; and (4) information on the provider’s policies
about the utilization of these rights.
In March 1992, the Indian Health Service (the Federal
Health Program for American Indians and Alaska Natives)
adopted the provisions of the PSDA, but with the follow-
ing condition: ‘Tribal customs and traditional beliefs that
relate to death and dying will be respected to the extent
possible when providing information to patients on these
issues’.3This proviso was included because of the Navajo
belief that language and thought have the power to alter,
control and shape the course of future events. Because of
this communal belief, Navajo custom and practices require
people to think and speak in positive terms. For the
Navajo, it is also improper to convey or receive negative
information (such as the disclosure of the risks relating to
a medical treatment or future illness) because that disclo-
sure in itself is perceived as having the power to produce
and amplify the negative conditions. In medico-ethical
decision making, the Navajo adhere to these beliefs, and
they form the basis of Navajo actions and inactions in var-
ious contexts (including medical contexts).
The problem of course is that, in adhering to the
requirements of informed consent, Western doctors typi-
cally convey information about the risks relating to a
treatment in a negative manner! This creates a problem:
should Western doctors on Navajo reservations adhere to
the standards of informed consent contained in the PSDA
and thereby risk harming their patients by the disclosure
of negative information, or should they convey only posi-
tive information (which would be in line with the Navajo
public health concerns require the combination of various
scientific skills and social action. Public health aims to
improve and maintain the health of all the people through
collective or social actions. Although the communal
dimensions of medicine are easily exhibited in public
health, medicine as a social institution can be conceived of
as a domain of inquiry that has as its goals the prevention
and reduction of disease, premature death and disability; the
prolongation of life and the promotion of physical and
mental health; the control of community infections; the
training and organization of professionals to diagnosis and
treat the infirm; and the development of other social mech-
anisms for the achievement of these social goals.
In this sociologistic/communal sense, medicine has
some key characteristics:
It is learned;
It is a field of human knowledge that studies and deals
with the organic, environmental, psychological and bio-
logical dimensions of human existence;
It is structured;
It is divided into aspects;
It is dynamic; and
It is variable.
Culture as individual beliefs
Culture in medicine is not just about socially variable
practices. It is also pyschologistic in the sense that it is a
manifestation of individual beliefs about ontology, meta-
physics and methods for the realization and achievement
of health, wholeness and wellness.The point here really is
that ‘all knowledge is to some extent concerned with the
knower: our attempts to know things about the natural
world are also part of a much larger attempt to understand
ourselves’.2And, in understanding ourselves as the know-
ing subject, we uphold various medicocultural beliefs. At
one level, these beliefs might just be about faith. But at
another (practical) level, they may form the content of
heuristic action-guiding principles that moderate and
affect human action.
So, a fourth basic way in which medicine is a cultural
good is that in which it is a repository of the concepts,
ideas, words, methods and other symbolic structures that
individuals rely on in their day to day living. In this sense
of the word, medicine as a cultural good is not just about
beliefs and values that we uphold; it is also about how we
internalise and operationalize these beliefs and values in
regulating and controlling the organic, environmental,
psychological and biological dimensions of human exis-
tence.
Culture can therefore be found not merely in com-
munal medical practices. Nor is it confined to explicitly
proclaimed beliefs. Cultural assumption can also be found
in unstated psychological assumptions about how we
understand, develop, treat and encounter ourselves. In this
psychologistic sense of medical culture, medical values are
not just about explicitly proclaimed beliefs, they are about
those unstated convictions that implicitly guide and gov-
ern practical conduct in issues of health, wholeness and
wellness. We may refer to these dimensions of culture as
practical beliefs. This would be a fifth sense in which
medicine encompasses culture.
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medicocultural beliefs) and thereby violate the ethical
requirement of informed consent?
The crux of the matter has to do with the nature of
medico-ethical ontology. In contemporary Western con-
ceptions of ethics, ethical and moral issues arise within the
context of interactions and contact among natural beings.
That is, issues of ethics come into discussion when we
consider the implications of human and/or animal actions
vis-à-vis other humans and animals. Let us describe this
Westernized conception of ethics as the ‘this-worldly’
approach to ethics. In the next section, I will give a
detailed account of an alternative medico-ethical ontology,
and then evaluate the implications of this alternative
ontology on the practice of medicine in contemporary,
multicultural,Western societies.
Culture and the practice of medicine:
the Yorùbá conception of Àrùn
(illness)
Yorùbá culture and Yorùbá medicine are currently prac-
ticed in all major Western societies (including the UK,
USA, Germany, Canada, France, Italy, Japan and Australia)
It is estimated that there are about 120 million worldwide
practitioners of Yorùbá culture. This culture, therefore
serves as a good benchmark for the discussion of rational-
ity and relativism in medico-ethical decision-making.
In Yorùbá culture and Yorùbá medicine, actions, activi-
ties and inactions involve three-way relationships among:
(1) natural beings (plants, animals and humans) and other
natural beings; (2) natural beings and spiritual beings; and
(3) spiritual beings and other spiritual beings. The Yorùbá
view the cosmos as a plain of existence in which there are
various subplains, the two most important subplains being
the right side (populated by good beings) and the left side
(populated by evil beings) (Figure 1).
The powers on the right-hand side are the Òrìsà (the
Gods). They are benevolent, but they sometimes punish
humans who corrupt society. The Yorùbá pray and offer
sacrifices to the Òrìsà in order to achieve their desires.
Humans, nature, plants and animals are also classified as
being on the right side of the cosmos.
Inhabitants of the left-hand side are the Ajogun (the
anti-Gods) and they are irredeemably malevolent. The
word Ajogun literally means ‘warrior’; hence the Ajogun
wage war against both humans and the Òrìsà. The eight
warlords of the Ajogun are: Ikú (Death), Àrùn (Disease),
Òfò (Loss), Ègbà (Paralysis), Òràn (Big Trouble), Èpè
(Curse), Èwòn (Imprisonment) and Èse (Affliction).
There are, however, two supernatural forces that strad-
dle both sides of the left/right divide. These are the Àjé
(who are usually improperly translated as ‘witches’) and
Èsù (the universal policeman). Èsù is a neutral element in
the sense that he is neither good nor bad. He is simply the
mediator between all the entities and forces on both sides
of the right/left divide.
Although the Àjé (‘witches’) also straddle the two
sides of the divide, they, unlike Èsù, are not neutral. They
are allies of the Ajogun. They suck human blood, eat
human flesh and they can afflict humans with various
types of diseases.The Àjé are, however,sometimes benevo-
lent.They can bless particular individuals by making them
rich and successful. But often, their blessings come at a
high price. For instance, it is believed that one of their
favourite prices is to ask for the child of whoever is seek-
ing their favour.
Because of Èsù’s neutrality and the fact that he is nei-
ther benevolent nor malevolent, he is regarded as an Òrìsà.
He has his own iconography, his own liturgy and priest-
hood. Human beings are also on the right-hand side of the
universe.Although humans are not regarded as supernatu-
ral powers, the belief is that every individual has the
potential to become a divinity.
What are the implications of these spiritualist beliefs
on the practice of medicine in Western societies? The best
way of introducing these differences is to start with a char-
acterization of the differences between orthodox and
alternative medicine in Western thought. Orthodox
medicine is, by and large, allopathic in the sense that its
methodology for the treatment of diseases is based on
what may be called the contrary principle: it attempts to
treat diseases with chemical agents that produce effects
that are contrary, or in opposition to, those of the disease
being treated. Moreover, allopathic medicine is also con-
cerned primarily with the elimination of symptoms.
Alternative medicine (in the Western sense of ‘alterna-
tive’) is homeopathic. Homeopathic medicine treats like
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Figure 1. Functional (health, wholeness and wellness) hierarchy
in the Yorùbá cosmos
This figure represents one functional hierarchical order in the
Yorùbá conception of the cosmos. As the High Deity in issues of
political administration of the cosmos, Olódùmarè would have
been at the apex of the Yorùbá pantheon had our interests been in
the political administration of the cosmos. But in the hierarchical
order depicted above, Òsanyìn is at the apex because I am inter-
ested in health, wholeness and wellness in the Yorùbá cosmos.
Note also that the Ajogun and the other evil supernatural forces
are on the left-hand side of the cosmos, and the good supernatu-
ral forces are on the right. The entities on the right are good by
nature, while those on the left are evil by nature. Olódùmarè (who
is regarded as the Chief Political Executive) and Èsù (who is
regarded as the universal policeman) straddle the left-side divide
because their adjudications and proclamations are required to bal-
ance the incessant conflict between the entities on the left and
those on the right. The Àjé also known as Eleye (Bird people) and
Eníyán (negative people) also straddle the left-right divide, but
they are regarded as evil. They are able to transverse the left-right
divide because they function through the agency of those Ènìyàn
(humans) who have given up their good human nature to
become Eníyán (Àjé or negative humans).
07.13.3.avma.07.pps 4/21/07 11:03 am Page 8
client’s Orí (i.e. each person’s personal divinity) and Ifá
(the God of wisdom) in a series of steps. So as to protect
the integrity of the divination act, the priest is not
informed about the nature of the client’s complaint until
after the divination.b(The client will simply whisper his
or her concerns to the divination instruments.) After a
series of invocations, the priest divines to determine the
Odù (book) of the Ifá Literary Corpus from which to
select a poem. The priest then explains and interprets the
message of the poem. Although there might be variations
in the depth of knowledge the priest brings to bear on his
or her interpretation of a poem, every specific poem has a
specific message.4
If, after divination, the onísègùn determines that the
source of the disease, illness or affliction is spiritual, then,
in addition to herbs and medications designed to treat and
repair the body, the onísègùn will also prescribe something
for spiritual repair. Sacrifice is compulsory after every div-
ination. But the onísègùn’s prescription may include
incantations and/or Ifá (Ifá here meaning special herbal
talismans, the recipes of which are contained in Ifá
poems). Indeed, it is precisely because of this that we have
the Yorùbá saying:‘ebo gí´ngín, òògùn gíngín níí gba aláìkú
là’ (‘it is a little bit of sacrifice and a little bit of medication
that saves the patient who is not going to die’).
The role of the Ajogun called Àrùn is very significant
for our current discussion. Àrùn has at least two layers of
meaning in the Yorùbá cosmos. First, it refers to an anti-
God (one of the Ajogun’s warlords). In Yorùbá theology,
the Ajogun are completely evil and as such they have no
redeeming virtues whatsoever. The avowed aim of all the
Ajogun, including Àrùn, is the complete ruination of
humankind. Only sacrifice and special pleading to Èsù by
one’s individual Orí can save one from the powers of the
Ajogun. And, indeed, all the divinities in the Yorùbá pan-
theon can be afflicted by the Ajogun.
In addition to Àrùn as an evil supernatural force, the
word ‘àrùn’ also means ‘illness’ or ‘disease’. Àrùn, as a bio-
logical defect in a human being, can be caused by natural
causes or by Àrùn (the malevolent supernatural force).This
explains why divination and sacrifice are important in
Yorùbá medicine. It is only through divination that a med-
ical practitioner can determine whether the cause of an
illness is natural or supernatural. Illnesses caused by natural
causes require herbal and pharmacological remedies. But
illnesses caused by supernatural forces require the offering
of sacrifice, the use of talismans and amulets, or the recita-
tion of incantations.The practice of medicine is, therefore,
not merely homeopathic in the sense that it relies only on
physical wholeness, it is also interested in spiritual balance.
In many contemporary Western societies, patients who
make use of Yorùbá medicine frequently go to onísègùn as
well as Western medical practitioners. Oftentimes, the diag-
nosis and prescriptions of these two practitioners will not
clash. But what if they do? Do we have to accept a multi-
culturalist relativist position in which there is no rational
means of choosing between these competing options?
Transculturalism and medicine: some
implications
The foregoing has various implications for the practice of
medicine in Western societies. I will consider two of these
with like: it employs herbal remedies, which, if given in
minute doses, would produce in a healthy person symp-
toms similar to those of the sick person. Moreover, while
allopathic medicine is preoccupied with getting rid of
symptoms, homeopathic medicine is more concerned with
identifying the causes of illness and disease in an effort to
restore holistic balance in the biological system. Yorùbá
medicine is homeopathic vis-à-vis the two main points
above: it is not just interested in getting rid of symptoms; it
is interested in identifying and removing the causes of ill-
ness, just as much as it is interested in maintaining holistic
balance. So, in their efforts to restore holistic balance in the
patient, the Yorùbá medical practitioner (onísègùna) will
also be interested in finding the spiritual causes of illness (if
there are any), just as much as he or she will be interested
in restoring spiritual balance in the patient (if necessary).
Restoring spiritual balance is important for two main
reasons. First, in Yorùbá thought the human being is made
up of four main components: (i) ara, the body, i.e. the
skeleton created by Ògún (a Yorùbá divinity), and the
form moulded by Obàtálá (another Yorùbá divinity); (ii)
èmí, that aspect of the soul which is imparted by
Olódùmarè (the High God) (note that the word ‘èmí’ is
also the Yorùbá word for ‘breath’); (iii) Orí, the principle of
material success; and (iv) ese, which introduces the princi-
ple of individual effort, strife or struggle before the poten-
tialities encapsulated in one’s Orí can be actualised. Ese, in
short, represents the idea that, ultimately, success is up to
the individual. Note that Èmí, ese and Orí (in this context)
are all spiritual, while Ara is corporeal. So, strictly speak-
ing, one should say that the person has two parts: ara (the
body) and the soul complex (èmí, Orí and esè).
Ifá divination is one important means of diagnosis
employed by the medical practitioner. In the divination
process, the priest establishes a link among the client, the
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aIt is important to note that traditional onísègùn are also diviners.
There are two main inter-related methods of divination in Yorùbá
culture: divination with the Ifá Literary Corpus in which there are
256 books and hundreds of poems within each book, and the
éérìndínlógún (sixteen cowries) divination system, a system which
condenses the 256 books of the Ifá Literary Corpus into sixteen.
The traditional onísègùn will be competent in at least one of
these two divination systems.I should also point out that there are
other traditional methods of divination (for example, kola-nut
divination). Also, in contemporary Yorùbá societies, there are now
many healers whose methods are not based on traditional Yorùbá
medicine. These would include: Christian healers who eschew
almost all forms of medication and concentrate on the power of
prayers and the holy water; and Islamic healers who make use of
the power of words derived from the Qur’an. Islamic healers also
depend heavily on talismans and amulets. My assertions here apply
only to the healing techniques of those healers who derive their
methods from traditional Yorùbá conceptions. I should also add
that there are some traditional Yorùbá healers who do not divine
at all. They are, however, not called onísègùn, they are called
adáhunse (a term which means something like ‘he or she who
does it alone’).
bEven this is not mandatory. It is not uncommon for clients to
choose not to reveal the precise nature of their problems to the
diviner.The client might, therefore, decide to listen to the priests’
chants, and interpretations of the poems chanted, and then ask
that the appropriate sacrifice for a particular poem be performed.
07.13.3.avma.07.pps 4/21/07 11:03 am Page 9
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implications: implications of alternative medicine on med-
ical ethics vis-à-vis the patient–client relationship and
implications on the problem of relativism.
Consider first, the context of medical ethical issues. In
contemporary Western conceptions of ethics, ethical and
moral issues arise within the context of interaction and
contact among natural beings. That is, issues of ethics
come into discussion when we consider the implications
of human and/or animal actions vis-à-vis other humans
and animals. In Yorùbá medicine, however, ethics is a
three-way relationship among: (1) natural beings and
other natural beings; (2) natural beings and spiritual
beings; and (3) spiritual beings and other spiritual beings.
What does this tell us about the nature of ethics gen-
erally, and medical ethics in particular? One crucial point
to emphasize here is that evil in Yorùbá culture (and in
Yorùbá medicine) is concrete in the sense that the anti-
Gods can manifest themselves as tangible, real or natural
effects.This is precisely why the most important warlords
of the Ajogun are Ikú (Death), Àrùn (Disease), Òfò (Loss),
Ègbà (Paralysis), Òràn (Big Trouble), Èpè (Curse), Èwòn
(Imprisonment) and Èse (Afflictions). The consequence of
this is that, although the Yorùbá distinguish between natu-
ral and moral evil, both types of evil can be the handi-
work of natural and supernatural beings.
In relation to Àrùn, sacrifice is believed to be the only
effective means of warding off this anti-God. Hence, in
relation to diseases caused by the anti-God, regular medi-
cation alone will not suffice as sacrifice would also be pre-
scribed. It should be noted that sacrifice is not merely
meant for the Gods and anti-Gods. Sacrifice in Yorùbá
culture is also a social act.This explains why, when asked
to offer a sacrifice to either a God, an anti-God, or, as
redemption for sin, a person will invite friends and neigh-
bours to a feast. The person will explain the reason why
he or she is offering the sacrifice, and his or her invitees
will offer prayers and blessings for that person. In the case
of sacrifice as redemption for moral evil, someone who
has not truly changed his or her ways is unlikely to
receive prayers and blessings from friends and neighbours.
The foregoing has major implications for the health
professional/patient relationship. What sort of duties,
responsibilities and rights attach to the roles of the
onísègùn and the client? Is the onísègùn ethically bound
to tell the whole truth to the patient even if this might be
inimical to a speedy recovery? The Hippocratic oath,
which has traditionally been the basis for Western medical
ethics, is silent on the issue of truth. In fact, with this oath
doctors merely pledge to ‘apply dietetic measures for the
benefit of the sick according to [the doctors’] ability and
judgment’.5Above all, doctors promise to protect their
patients from ‘harm and injustice’.
Based upon the Hippocratic oath in which protection
against harm is paramount, the traditional model of
responsibility that emerged within the practice of Western
medicine was that of paternalism in which the physician’s
duty to tell the truth was subordinate to that of not harm-
ing the patient. In contrast to paternalism, many have
argued that patient autonomy should be the basis of the
physician–patient relationship. Neither of these models
suits the onísègùn–client–divinities relationship because
even the onísègùn is an interpreter who is decoding or
attempting to decipher the messages of the Gods. The
Yorùbá medical practitioner is not being paternalistic
because, as an interpreter, her prescriptions and directions
cannot be based on the hierarchical structure of a family-
based patriarchy – a structure in which the pater (or
father) is the person at the apex who is making the deci-
sions on behalf of his ‘children’ for their own good, even if
this is contrary to their wishes. Nor can the Gods be
regarded as the pater at the apex of the Yorùbá hierarchy
because the anti-Gods are often the ones in control.
Autonomy as the basis of the patient–client relation-
ship does hold some promise in Yorùbá medicine.After all,
the client, even in Yorùbá medicine, in some sense exer-
cises some level of freedom in choosing between Yorùbá
and Western medicine, in the decision to accept and per-
form the prescribed sacrifice. So within the contexts of
this-worldly choices vis-à-vis action in relation to the ill-
ness, the client can to some extent be regarded as having
the capacity, as an individual that makes rational, individ-
ual, informed and uncoerced decisions. However, this
autonomy is severely diminished by the supernaturalistic
dimensions of Yorùbá medicine. For, given the avowed
enmity between Gods and anti-Gods, anti-Gods and
humans, and indeed the occasional scuffles between Gods
and Gods, humans can never truly be free.
Let us now address the issue of relativism. The prob-
lem is this: in a society where there are competing (and
often conflicting) paradigms, should the physician always
accept and respect contradictory choices (made from
within other paradigms) as equally valid? Although a lot
of confusion has been wroth on the issue of multicultural-
ism and relativism, I think this is the least problematic of
the problems of cross-cultural comparisons in medical
decision-making. As I have already argued above,
medicine is a cultural good in any culture. That is,
medicine is about the use of exemplary techniques that
have been learnt, nurtured and transmitted in a society in
such a way that these exemplary techniques become part
of the community and individuals’ methods for the mod-
eration, regulation and control of action and inaction in
issues of health, wholeness and wellness.
Differently put, medicine is not an end in itself – it is
a means to an end and as a result of this, different
paradigms of medicine can be evaluated in two ways:
internally and externally. Internally, we can ask whether
the methods and heuristic action-guiding principles
adopted by a paradigm are consistent with the goals of
that paradigm. Moreover, the methods adopted by each
paradigm must be internally consistent (i.e. they must be
free of contradictions); they must be realizable or achiev-
able within the confines of that paradigm; these methods
must also be in congruence with the values implicit in the
communal practices that give rise to them. This is of
course an instrumentalist justification of medical decision-
making.
Consider, for instance, the following example of the
switch from single-blind techniques to double-blind ones
in clinical trials. Until relatively recently, double-blind tri-
als were not part of the ‘methodology’ of Western clinical
trials. This switch could be stated as the following pre-
scriptive rule:
If you want to determine whether a drug genuinely has
specified physiological effects, prefer double-blind clinical
trials to single-blinded ones.
07.13.3.avma.07.pps 4/21/07 11:03 am Page 10
AvMA Medical & Legal Journal 117
The AvMA Medical & Legal Journal 2007 Volume 13 Number 3
cient for assessing the rationality of human conduct (and
choices):
1. [An] act Aviolates powerful social standards of conduct
embedded in the judgements of [a person] P,as well as
the community or group(s) in which P’s activity is em-
bedded;
2. P’s subjective ends Eare so bizarre, idiosyncratic, inco-
herent, illegitimate or misguided by reference to pow-
erful social norms of conduct embedded in the
judgements of P’s community of peers, as to make P’s
action Aseem senseless, incoherent, mad or otherwise
inappropriate; and
3. P’s background of beliefs Bis itself so inconsistent,irra-
tional, idiosyncratic or unstable relative to epistemic
standards embedded in the judgements of P’s com-
munity or peers, as to make Pan irrational agent, no
matter how effective A is, to the realization of E.6
The point is that we can have situations of instrumental
efficacy (hence, mini-rationality) which violate any of the
three (especially 2 and 3) circumstances above. Irrespective
of whether the action or choice was instrumentally effica-
cious in bringing the actors’ goal to fruition, we will still
pronounce such actions and choices maxi-irrational.
But this brings us back to the transcultural cultural
goods of medicine: implicit in the five cultural goods I
have identified is a more fundamental good about the need
to maintain health and wholeness.And as such, even when
paradigms of medicine adopt methods that are in conflict,
they are mostly still concerned with an attempt to deliver
good health, wellness and wholeness. Of course, people
(from within the same paradigm and from different
paradigms of medicine) have disagreed and will continue,
hotly, to disagree about how to correctly and exactly char-
acterize good health, wellness and wholeness. Nonetheless,
this super-value of health, wellness and wholeness can
function as a transcultural, but external, benchmark against
which the delivery and practice of medicine in any specific
culture can be assessed. Transculturalism, therefore, avoids
the pitfalls of relativism (and multiculturalism) because of
its reliance on internal and external criteria in the evalua-
tion of medicocultural paradigms.
Acknowledgement
This article is based on material from The Sydney Brandon
Memorial Lecture, which I delivered at the Annual General
Meeting of the Leicestershire Medico–Legal Society,
Leicester, UK, on 18 January 2007. I would like to thank
Eric Mason for his comments and suggestions.
References
1Flowers BJ, Richardson FC. Why is multiculturalism good?
American Psychologist 1996; 51: 609–621
2Evans HM. Is medicine a ‘cultural good’? MJA 2005; 182: 3–4
3Carrese J, Rhodes LA.Western bioethics on the Navajo reservation:
benefit or harm. JAMA 1995; 274: 826–829
4Abímbólá W. Ifá: An Exposition of Ifá Literary Corpus. Ìbàdàn:
Oxford University Press,1976
5Arras JD, Steinbock B. Ethical Issues in Modern Medicine.
Mountain View, CA: Mayfield Publishing Company, 1995
6Doppelt G.The naturalist conception of methodological standards in
science: a critique. Philosophy of Science 1990; 57: 1–19
This instrument justification of double-blind method-
ology in Western medicine is justified on the grounds that
the advancement of knowledge has made scientists realize
that the reassuring act of receiving medication and medi-
cal attention often has curative effects on patients – even
when they have been given pharmacologically inert
drugs. This is the placebo effect. To control the placebo
effect in the testing of drugs, controlled experiments are
performed on a group of patients. The group of patients
on which the clinical trial is to be performed is subdi-
vided into two groups: the test group and the control
group. Patients in the test group are administered the drug
under test, while patients in the control group receive a
pharmacologically inert drug which looks like the true
drug. But as patients in either group will not know to
which group they belong (i.e. patients will not know
whether they are receiving the real drug or the dummy
drug) the problem of the placebo effect was regarded as
eliminated.This is the single-blind test.
But as we learn more about therapeutic effects, we
come to realize that in single-blind tests, researchers can,
and often do, convey their own therapeutic expectations
to the test patients; hence, the placebo effect could still
recur in single-blind tests. Moreover, doctors’ expectations
might affect their judgement as to whether a patient had
benefited from a certain treatment. So it becomes prefer-
able to perform clinical trials double-blind. In double-
blind trials, neither the patients nor those who conduct
the experiment know which patient receives the genuine
drug and which the dummy drug. As double-blind trials
eliminate a possible source of error which single-blind
tests do not, double-blind tests are a more effective means
for determining whether drugs genuinely have the thera-
peutic effects they are said to have.
The use of double-blind techniques in Western clinical
trials is obviously desirable, but in Yorùbá medicine, it is
not applicable.The method that is applicable at the diag-
nosis stages of Yorùbá medicine is a single-blind method in
which the client does not disclose her concerns to the
onísègùn. In the diagnosis stages of the divination process,
the client does not divulge her concerns to the diviner
directly. Rather she whispers her concerns to the instru-
ments of divination, and the diviner has to continue inter-
preting poems until the client is satisfied that she has
acquired the appropriate level of guidance required.
Conclusions
I have maintained that instrumental efficacy, consistency
and achievability within the confines of specific paradigms,
and congruence with the values implicit in communal
practices that give rise to methods, provide us with a set of
criteria for evaluating, by the effectiveness of means in
bringing ends, the realization in the practice of medicine.
This is because rationality is to a large extent agent- and
context-specific.When we evaluate an action or inaction of
an individual as rational, we are at the very least claiming
that the actor acted in ways which she believed would pro-
mote her ends. It should be noted, however, that while an
instrumental mean-ends assessment of actions may be nec-
essary for rationality, it may not be sufficient.
Doppelt,6for example, identifies the following three
circumstances in which instrumental efficacy are insuffi-
07.13.3.avma.07.pps 4/21/07 11:03 am Page 11
... Medicine is intricately intertwined with cultural goods in these two senses above: it is about the achievements of a society in its quest to understand itself as the socio-biological knower, just as much as it is about the cultivation and transference of knowledge about us as the medical subject (Abimbola 2007). There are four further dimensions to the two cultural aspects of medicine: the communal, the individualistic, the archival, and the practical. ...
... Culture can therefore be found not merely in communal medical practices (Abimbola, 2007). Neither is it confined to explicitly proclaimed beliefs. ...
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